Ethno-knowledge and attitudes regarding snakebites in the Alto Juruá region, Western Brazilian Amazonia

Vulnerability factors of snake bite patients in China

OBJECTIVE

To analyze the vulnerability factors of snakebite patients in China.

METHODS

Multi-stage random sampling was used as the main sampling method and snowball sampling as the auxiliary sampling method. The knowledge, attitude and behavior of snakebite among Chinese residents were investigated. Non-parametric test was used to compare the percentage differences in residents' knowledge, attitude and behavior of snakebite, and generalized linear regression analysis was used to analyze the influencing factors, and the vulnerability factors of snakebite patients were comprehensively analyzed.

RESULTS

A total of 6338 subjects were included in this study, of which 68.4% were males, and 58.6% were farmers, workers and service personnel. The median total score of knowledge, attitude, and behavior was 26 (22,36). The patients who were improperly treated after injury were ligation proximal to the affected area (23.43%), squeezing (21.82%), and oral and suction wounds (8.74%). Did not go to hospital due to poverty (1351 cases) and did not receive antivenom (2068 cases). There were 21.32% and 32.63%, respectively. Among 4270 patients injected with antivenom 30.7% were vaccinated within 2 h. Among the patients who went to the hospital for treatment (4987), 75.0% arrived at the hospital within 6 h; Among the 4,761 patients who made emergency calls, 37.4% were treated within 0.5 h.

CONCLUSIONS

Snakebite patients in China have weak knowledge about snakebite, low awareness of medical treatment, lack of correct prevention and emergency treatment measures, dependence on folk remedies, poor housing and so on. In addition, there are low availability of antivenoms and unreasonable distribution of medical resources in some areas of China. Multisectoral and multidisciplinary cooperation should be developed to prevent and control snakebites in order to reduce the burden caused by snakebites.

First aid and pre-hospital practices in snakebite victims: The persistent use of harmful interventions

First aid intervention and pre-hospital (FAPH) practices are common in patients suffering from snakebite envenomation (SBE). In this study, we have reviewed the literature concerning the use of these practices in various regions of the world in the period 1947-2023 based on published prospective studies. A total of 71 publications fulfilled the inclusion criteria. In terms of the total number of patients in all studies that used each FAPH intervention, the most common practice was the application of tourniquets (45.8%). Other FAPH practices described include cuts/incisions (6.7%), the application of a variety of natural or synthetic substances at the bite site (5.6%), and ingestion of natural, usually herbal, remedies (2.9%). Washing the site of the bite was described in 9.1% of patients. There were other less frequent FAPH practices, including suction, splinting-immobilization, pressure-bandage, ice packs, application of a snake/black stone, and administration of alcoholic beverages. There were differences in the extent of application of FAPH interventions in different continents. Tourniquets were highest (55.7%) in Asia. Topical application of various products was common in South America, while pressure-bandage was only reported in Australia. We did not find any statistically significant variations in the frequency of the most frequent FAPH interventions at three-time intervals (before 2006, between 2006 and 2015, and after 2015). Our findings highlight the use of FAPH interventions in patients suffering SBE, some of which are known to be harmful. It is necessary to study these practices to a higher level of geographic granularity, using community-based surveys. Programs tailored to local contexts should be promoted, aimed at avoiding the use of harmful FAPH practices. It is also necessary to assess the efficacy and safety of some interventions through robust preclinical and clinical studies.

Photobiomodulation Therapy to Treat Snakebites Caused by Bothrops atrox: A Randomized Clinical Trial

Importance

Bothrops venom acts almost immediately at the bite site and causes tissue damage.

Objective

To investigate the feasibility and explore the safety and efficacy of low-level laser therapy (LLLT) in reducing the local manifestations of B atrox envenomations.

Design, Setting, and Participants

This was a double-blind randomized clinical trial conducted at Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, Brazil. A total of 60 adult participants were included from November 2020 to March 2022, with 30 in each group. Baseline characteristics on admission were similarly distributed between groups. Data analysis was performed from August to December 2022.

Intervention

The intervention group received LLLT combined with regular antivenom treatment. The laser used was a gallium arsenide laser with 4 infrared laser emitters and 4 red laser emitters, 4 J/cm2 for 40 seconds at each application point.

Main Outcomes and Measures

Feasibility was assessed by eligibility, recruitment, and retention rates; protocol fidelity; and patients' acceptability. The primary efficacy outcome of this study was myolysis estimated by the value of creatine kinase (U/L) on the third day of follow-up. Secondary efficacy outcomes were (1) pain intensity, (2) circumference measurement ratio, (3) extent of edema, (4) difference between the bite site temperature and that of the contralateral limb, (5) need for the use of analgesics, (6) frequency of secondary infections, and (7) necrosis. These outcomes were measured 48 hours after admission. Disability assessment was carried out from 4 to 6 months after patients' discharge. P values for outcomes were adjusted with Bonferroni correction.

Results

A total of 60 patients (mean [SD] age, 43.2 [15.3] years; 8 female individuals [13%] and 52 male individuals [87%]) were included. The study was feasible, and patient retention and acceptability were high. Creatine kinase was significantly lower in the LLLT group (mean [SD], 163.7 [160.0] U/L) 48 hours after admission in relation to the comparator (412.4 [441.3] U/L) (P = .03). Mean (SD) pain intensity (2.9 [2.7] vs 5.0 [2.4]; P = .004), circumference measurement ratio (6.6% [6.6%] vs 17.1% [11.6%]; P < .001), and edema extent (25.8 [15.0] vs 40.1 [22.7] cm; P = .002) were significantly lower in the LLLT group in relation to the comparator. No difference was observed between the groups regarding the mean difference between the bite site temperature and the contralateral limb. Secondary infections, necrosis, disability outcomes, and the frequency of need for analgesics were similar in both groups. No adverse event was observed.

Conclusions and Relevance

The data from this randomized clinical trial suggest that the use of LLLT was feasible and safe in a hospital setting and effective in reducing muscle damage and the local inflammatory process caused by B atrox envenomations.

Trial Registration

Brazilian Registry of Clinical Trials Identifier: RBR-4qw4vf.

Snakebites in Northeastern Brazil: accessing clinical-epidemiological profile as a strategy to deal with Neglected Tropical Diseases

BACKGROUND

Brazil ranks first in the number of snakebites in South America. A detailed analysis of these cases is required to improve the public health planning. In this study, we retrospectively examined the clinical and epidemiological profiles of snakebites in Maranhão between January 2009 and December 2019.

METHODS

Data were obtained from the compulsory notification forms provided by the Health Department of Maranhão.

RESULTS

A total of 17,658 cases were recorded during the study period. Most of the bites were from snakes belonging to the genus Bothrops. Medical care was mostly within three hours after the bite. Most cases were classified as mild and most victims recovered; however, 139 deaths were recorded. Most bites occurred among people aged 20-39 years, mainly among rural workers. The most frequent local clinical manifestations were pain, edema, and ecchymosis. The most common systemic clinical manifestations include neuroparalysis, vagal syndrome, and myolysis. Most snakebites occurred between January and March. The municipalities with the highest number of notifications were Buriticupu (936 cases), Arame (705 cases), and Grajaú (627 cases).

CONCLUSIONS

The clinical profile of snakebites in Maranhão is similar to that observed in other states of Northeast Brazil. However, we found that some systemic manifestations are not compatible with the etiology of snakebites, which leads us to believe that the problem could be the lack of knowledge of the health professionals at the site of envenomation, who may not be ready for attendance, and an important lack of health centers with snake antivenom to treat snakebites.

Who are the most affected by Bothrops snakebite envenoming in Brazil? A Clinical-epidemiological profile study among the regions of the country

Snakebite envenoming represents an important Neglected Tropical Disease (NTD) that mainly affects tropical and subtropical developing countries according to the World Health Organization (WHO). As a priority issue in the tropics, it is estimated that accidental encounter between snakes and humans is the leading cause of morbidity and mortality among all NTDs in the world. In Brazil, an extremely diverse country with continental dimensions, snakebite envenoming is the second leading cause of reported human envenoming. Treating the disease has been an unprecedented challenge for Brazilian Health Systems for decades. Despite access to Antivenom therapy and distributing it free of charge across the country, Brazil faces numerous issues regarding the notification process and accurate treatment targeting for at-risk populations. Thus, this study aimed to identify the temporal epidemiological dynamics of accidents caused by Bothrops snakes in Brazil, the country's major group of venomous snakes, based on secondary information from the online database provided by The Brazilian Notifiable Diseases Information System (SINAN). For this purpose, reported Bothrops snakebites between 2012 and 2021 were counted, then the data were analyzed. We looked at the frequency, occurrence, mortality rates, case fatality rate (CFR), age and gender distribution, and the time lapse between the incident and the initiation of Antivenom therapy. The data were also organized considering regional variations of the country. Throughout the studied period, a total of 202,604 cases of envenoming caused by Bothrops spp. were notified, resulting in 766 fatalities. These accidents were found to occur in variable proportions across different regions in Brazil, with notable concentrations observed in the North, Northeast, and Southeast regions. The epidemiological profile of patients varied greatly between the regions, revealing that snake envenoming is much more a social, economic, and ecological problem than a medical one. In conclusion, our study provides an overview of the clinical and epidemiological profile of envenoming by Bothrops snakes in Brazil. Notably, this is the first study to present such information in a country as vast and diverse as Brazil, encompassing a comparative analysis of its regions using SINAN data, that proves to be a very useful national tool to improve the control and management of envenoming.

Snakebite envenomations and access to treatment in communities of two indigenous areas of the Western Brazilian Amazon: A cross-sectional study

BACKGROUND

The indigenous populations of Brazil present poor health indicators and a disproportionate prevalence and case-fatality rate of neglected tropical diseases, including snakebite envenomations (SBEs). This study aims to estimate access to medical care for SBEs and analyze the barriers that prevent victims from accessing healthcare in indigenous communities in two health districts located in the Western Brazilian Amazon.

METHODOLOGY/PRINCIPAL FINDINGS

This cross-sectional study used semi-structured interviews to collect data from individuals who experienced SBEs in the Upper Rio Solimões and Upper Rio Negro indigenous health districts. Of the 187 participants, 164 (87.7%) reported that they had access to healthcare and received assistance in a hospital in the urban area of the municipalities. Frequency was 95.4% in the Upper Rio Solimões SIHD, and 69.6% in the Upper Rio Negro SIHD (P<0.0001). The study found that the availability of indigenous medicine as the only choice in the village was the main reason for not accessing healthcare (75%), followed by a lack of financial resources and means of transportation (28.1%). Four deaths were reported from SBEs, resulting in a case-fatality rate of 2.1%.

CONCLUSIONS/SIGNIFICANCE

In the study areas, there are records of SBE patients who did not receive medical attention. Availability of pre-hospital emergency transport using motorboats, a greater number of hospitals and better navigability of the Solimões River and its tributaries would make access easier for indigenous people living in the region of the Upper Solimões River. The implementation of cross-cultural hospital care needs to be considered in order to reduce the resistance of indigenous populations in relation to seeking treatment for SBEs.

Morbidity survey of the history of snakebites in different communities in the alto Juruá, western Brazilian Amazon

The Alto Juruá region has a rich diversity of venomous snakes, and snakebites represent an important cause of morbidity. The present study was carried out in five communities in the Alto Juruá region, and aimed to evaluate the history of snakebites in terms of which snakes were involved and what was the victims' conduct in relation to first aid and prevention. Between 2017 and 2019, semi-structured interviews were applied to 260 residents, 56 (21.53%) of whom had a history of snakebites. The profile of the victims is 73.2% male, a resident of rural areas who develops activities mainly in agriculture and extractivism and who has a low level of education. Just over half of the snakebites occurred during the rainy season (52.8%) and the majority during the day (77%). Bothrops bites were the most frequently reported (90.3%) and B. atrox was the most mentioned snake (jararaca and surucucu) for being responsible for snakebites (80.8%). Approximately 87.5% of the bites occurred to the lower limbs, and 48.2% of the victims were barefoot at the time of the bite. Inadequate first-aid procedures were reported, such as using tourniquets and consuming the drink known as "Específico Pessoa", not drinking water, and treatment with traditional therapy (phytotherapics, zootherapeutics and faith healers), as well as not seeking hospital care. Thus, the need to facilitate access to hospital units in these communities and health education (prevention and first aid) are essential in order to minimize this situation.

Snakebite envenoming in Brazilian children: clinical aspects, management and outcomes

Snakebite envenoming is currently considered a neglected tropical disease, which affects over 5 million people worldwide, and causes almost 150 000 deaths every year, as well as severe injuries, amputations and other sequelae. Snakebite envenoming in children, although proportionally less frequent, is generally more severe, and represents an important challenge for pediatric medicine, since they often result in worse outcomes. In Brazil, given its ecological, geographic and socioeconomic characteristics, snakebites are considered an important health problem, presenting approximately 30 000 victims per year, approximately 15% of them in children. Even with low snakebite incidence, children tend to have higher snakebite severity and complications due to the small body mass and same venom volume inoculated in comparison to adults, even though, due to the lack of epidemiological information about pediatric snakebites and induced injuries, it is difficult to measure the treatment effectiveness, outcomes and quality of emergency medical services for snakebites in children. In this review, we report how Brazilian children are affected by snakebites, describing the characteristics of this affected population, clinical aspects, management, outcomes and main challenges.

The bioprospecting potential of Clusia fluminensis Planch. & Triana: a scoping review

Many biological activities are described for the Clusiaceae family. Clusia fluminensis, a species from Brazilian flora, is mainly employed for ornamental purposes. This review aimed to depict the current knowledge of C. fluminensis from a bioprospecting standpoint. "Clusia fluminensis" search term was applied in Scopus, Web of Science, PubMed and Bireme databases according to PRISMA-ScR statement. Selected papers on Phytochemistry or Bioactivity followed hand searching procedures. Bioactivity preclinical studies considered in vitro or in vivo biological systems, treated with plant extracts or isolated compounds. The outcomes were compared with standard or no treatment control groups. Critical appraisal of individual trials considered completeness in the research fields. Our results showed that 81% of the selected papers presented high level of completeness, 69% revealed phytochemical parameters and 31% biological applications of plant extracts and isolated compounds. Polyisoprenylated benzophenones, terpenoids, sterols and phenolic compounds were identified. Antiviral, insecticidal and snake antivenom activities were reported. In conclusion, the phytochemical data reinforce the reported activities. Potential applications in personal care, nutritional supplementation and pharmaceutical, food, chemical or textile industries were also identified. Toxicological and phytochemical complementary studies may be required.

Mapping of clinical management resources for snakebites and other animal envenomings in the Brazilian Amazon

Snakebite envenomings (SBEs) and other envenomings triggered by venomous animals (VAEs) represent a significant disease burden in Brazil, with 29,152 SBEs reported in 2021 alone with nearly half of those occurring in the remote Brazilian Amazon. In 2021, Brazil recorded 240,294 envenomings from snakes, scorpions, spiders, and caterpillars. Therefore, there is an unequal distribution of SBEs with high morbidity and mortality in the Brazilian Amazon. The severity of SBEs increases when patients require more than 6 h to access antivenom treatment, a common issue for the rural and indigenous populations. Understanding currently available resources and practices in Amazon remote areas of Brazil can serve to inform future interventions and guide health care policies. This study aims to develop a resource map of existing healthcare resources for the Brazilian Amazon's clinical management of VAEs with emphasis in SBEs, which will aid future strategic interventions. Data collection included a literature review, secondary data collected by government departments and organizational records, GIS mapping activities, and expert input. Our framework was guided by the three levels of healthcare service ecosystem analysis (macro, meso, and micro). Our resource map lays out a comprehensive overview of antivenom access, the distribution landscape, differences in patient transportation, and barriers to access healthcare that face populations in the Brazilian Amazon.

Temporal trend and epidemiological profile of accidents involving venomous animals in Brazil, 2007-2019

OBJECTIVE

to analyze the temporal trend of accidents involving venomous animals in Brazil from 2007 to 2019.

METHODS

this was a cross-sectional study carried out with data from the Notifiable Health Conditions Information System (SINAN). Prais-Winsten linear regression was used for the temporal analysis. We calculated incidence rates according to sex and age group, relative risk and case fatality ratio.

RESULTS

during the study period there were 2,102,657 cases of accidents involving venomous animals. With the exception of snakebite, the remaining accidents showed a rising temporal trend in most regions of the country. Scorpion stings, snake bites and spider bites were responsible for 86% of accidents, mainly affecting male people of working age. Accidents involving snakes (0.4%) and bees (0.3%) had the highest case fatality ratios. Children were the main victims of accidents involving bees, caterpillars and "others".

CONCLUSION

accidents involving venomous animals showed a rising temporal trend for most conditions, as well as different epidemiological profiles.

Bothrops bilineatus: An Arboreal Pitviper in the Amazon and Atlantic Forest

The two-striped forest-pitviper (Bothrops bilineatus) is an arboreal snake that is currently represented by two subspecies (B. b. bilineatus and B. b. smaragdinus) that comprise a species complex, and its distribution is in the Amazon and the Atlantic Forest. The rarity of encounters with this snake is reflected in the low occurrence of cases of snakebites throughout its geographic distribution and the resulting low number of published clinical reports. However, in some areas, B. bilineatus proves to be more frequent and causes envenomations in a greater proportion. Herein, we review the main aspects of the species complex B. bilineatus, including its biology, ecology, taxonomy, morphology, genetic and molecular studies, geographic distribution, conservation status, venom, pathophysiology and clinical aspects, and epidemiology. In addition, the different antivenoms available for the treatment of envenomations caused by B. bilineatus are presented along with suggestions for future studies that are needed for a better understanding of the snakebites caused by this snake.

Access to antivenoms in the developing world: A multidisciplinary analysis

Access to safe, effective, quality-assured antivenom products that are tailored to endemic venomous snake species is a crucial component of recent coordinated efforts to reduce the global burden of snakebite envenoming. Multiple access barriers may affect the journey of antivenoms from manufacturers to the bedsides of patients. Our review describes the antivenom ecosystem at different levels and identifies solutions to overcome these challenges. At the global level, there is insufficient manufacturing output to meet clinical needs, notably for antivenoms intended for use in regions with a scarcity of producers. At national level, variable funding and deficient regulation of certain antivenom markets can lead to the procurement of substandard antivenom. This is particularly true when producers fail to seek registration of their products in the countries where they should be used, or where weak assessment frameworks allow registration without local clinical evaluation. Out-of-pocket expenses by snakebite victims are often the main source of financing antivenoms, which results in the underuse or under-dosing of antivenoms, and a preference for low-cost products regardless of efficacy. In resource-constrained rural areas, where the majority of victims are bitten, supply of antivenom in peripheral health facilities is often unreliable. Misconceptions about treatment of snakebite envenoming are common, further reducing demand for antivenom and exacerbating delays in reaching facilities equipped for antivenom use. Multifaceted interventions are needed to improve antivenom access in resource-limited settings. Particular attention should be paid to the comprehensive list of actions proposed within the WHO Strategy for Prevention and Control of Snakebite Envenoming.

Ethnozoology of snakebite victims in a risk area in Northeast Brazil

This study had the objectives to describe and analyze the perceptions and attitudes of snakebite victims in the semi-arid region of Northeast Brazil. A semi-structured questionnaire was applied as snakebite victims to identify the characteristics of the accident, their daily life, as well as positive and negative attitudes towards snake conservation and knowledge about species. Information about the possible uses of traditional treatment, allopathic care characteristics along with the symptoms and sequelae resulting from the accident were also recorded. The results obtained revealed that accidents mostly occurred during the development of their daily activities (i.e. during agricultural activities, in hunting activities in the mountains, in caring for farm animals, etc); most accidents are associated with Caatinga lancehead (Jararaca; Bothrops erythromelas); the bites usually affect the limbs, 75% (n = 46) feet, and the victims resort to medical assistance for specific treatment, although some seek this service after using or ingesting medicinal or popular/home-made therapeutic resources. The most relevant characteristics detected in these accidents were the strong influence of myths about traditional treatment (20%, n = 12) and the knowledge about identifying common snake species in the region (66%, n = 40). No perception was detected about the importance of these animals, but there were negative attitudes when finding a snake, fear/panic (34%, n = 21); kill the snake (23%, n = 14), thus constituting facts which may be related to the deficiency in the education level of this population which is interfering in environmental and public health issues. Work on improving the knowledge and local perception could subsidize actions and policies aimed to prevent accidents, demystify snakes and contribute to the conservation of the species.

Snakebites in "Invisible Populations": A cross-sectional survey in riverine populations in the remote western Brazilian Amazon

In the Brazilian Amazon, long distances, low healthcare coverage, common use of ineffective or deleterious self-care practices, and resistance to seeking medical assistance have an impact on access to antivenom treatment. This study aimed to estimate snakebite underreporting, and analyze barriers that prevent victims from obtaining healthcare in communities located in 15 municipalities on the banks of the Solimões, Juruá and Purus Rivers, in the remote Western Brazilian Amazon. Information on the participants' demographics, previous snakebites, access to healthcare, time taken to reach medical assistance, use of self-care practices, and the reason for not accessing healthcare were collected through semi-structured interviews. In the case of deaths, information was collected by interviewing parents, relatives or acquaintances. A total of 172 participants who reported having suffered snakebites during their lifetime were interviewed. A total of 73 different treatment procedures was reported by 65.1% of the participants. Participants living in different river basins share few self-care procedures that use traditional medicine, and 91 (52.9%) participants reported that they had access to healthcare. Living in communities along the Juruá River [OR = 12.6 (95% CI = 3.2-49.7; p<0.001)] and the use of traditional medicine [OR = 11.6 (95% CI = 3.4-39.8; p<0.001)] were variables that were independently associated to the lack of access to healthcare. The main reasons for not accessing healthcare were the pprioritization of traditional treatments (70.4%), and the failure to recognize the situation as being potentially severe (50.6%). Four deaths from complications arising from the snakebite were reported, and three of these were from communities on the banks of the Juruá River. Only one of these received medical assistance. We found an unexpectedly high underreporting of snakebite cases and associated deaths. Snakebite victims utilized three main different healing systems: 1) self-care using miscellaneous techniques; 2) official medical healthcare generally combined with traditional practices; and 3) self-care using traditional practices combined with Western medicines. To mitigate snakebite burden in the Brazilian Amazon, an innovative intervention that would optimize timely delivery of care, including antivenom distribution among existing community healthcare centers, is needed.

Integrating lay knowledge and practice into snakebite prevention and care in central Africa, a hotspot for envenomation

The WHO has identified the goal of halving deaths and disability from snakebite envenomation (SBE) by 2030 through a four-pillar program that promotes accessible and affordable treatments, strengthens health systems, promotes community and multi-level engagement, and mobilizes partnerships, coordination and resources to advocate for global action. This initiative could accelerate multi-disciplinary research and action in central Africa, a “hotspot” for SBE, but it offers little specific guidance about anthropological research to be conducted. This commentary develops that research agenda. It surveys anthropological, ethnohistorical investigations in the central African forest to elaborate the socio-cultural and historical significance and practices around snakes and snakebites. It draws from south and southeast Asian and Latin American literatures to illustrate anthropological contributions to SBE research. It then outlines a Central African research agenda employing ethnobiological investigation of snake ecologies, participatory evaluations of humans-snake contacts, and interviews and participant-observation of local prevention and treatment practices and knowledge. This research will co-develop policies and practices with forest communities and leaders and regional and national authorities to reduce the burden of SBE.

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Central African forests are a hotspot for snakebite envenomation.

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SBE research in central Africa has not mobilized anthropological literatures or methodologies.

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Policies to reduce SBE burden in central Africa should build on participatory research.

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Policies to reduce SBE burden should be co-developed with local and national stakeholders.

Efficacy of the 20-minute whole blood clotting test (WBCT20) in the diagnosis of coagulation alteration related to snakebites in a Western Brazilian Amazon hospital

Introduction:

The efficacy of 20-minute whole blood clotting (WBCT20) and the Lee-White clotting time (LWCT) tests in diagnosing coagulation alterations from snakebites were compared.

Methods:

We evaluated 89 snakebite cases treated at the Hospital Regional do Juruá em Cruzeiro do Sul, Acre, Brazil.

Results:

WBCT20 results were normal in 33.7% and unclottable in 66.3% of cases, while LWCT results were normal in 23.6% and altered (prolonged or unclottable) in 76.4% of cases, with no significant differences.

Conclusions:

The WBCT20 is important for rapidly diagnosing coagulation alterations from snakebites. Furthermore, it is efficient, inexpensive, and can be deployed in isolated hospitals.

A painful journey to antivenom: The therapeutic itinerary of snakebite patients in the Brazilian Amazon (The QUALISnake Study)

Access to antivenoms is not guarranteed for vulnerable populations that inhabit remote areas in the Amazon. The study of therapeutic itineraries (TI) for treatment of snakebites would support strategies to provide timely access to users. A TI is the set of processes by which individuals adhere to certain forms of treatment, and includes the path traveled in the search for healthcare, and practices to solve their health problems. This study aims to describe TIs of snakebite patients in the Brazilian Amazon. This study was carried out at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, state of Amazonas, Brazil. The itinerary from the moment of the bite to the patient's admission to the reference unit was analyzed. Sample size was defined by saturation. After an exploratory survey to collect epidemiological variables, in-depth interviews were conducted following a semi-structured guide. Patients originated from rural areas of 11 different municipalities, including ones located >500 kilometers from Manaus. A great fragmentation was observed in the itineraries, marked by several changes of means of transport along the route. Four themes emerged from the analysis: exposure to snakebite during day-to-day activities, use of traditional therapeutic practices, and personal perception of the severity, as well as the route taken and its contingencies. Access to healthcare requires considerable effort on the part of snakebite patients. Major barriers were identified, such as the low number of hospitals that offer antivenom treatment, poor access to healthcare due to long distances and geographic barriers, low acceptability of healthcare offered in countryside, lack of use of personal protective equipment, common use of ineffective or deleterious self-care practices, late recognition of serious clinical signs and resistance to seeking medical assistance. Health education, promotion of immediate transport to health centers and decentralization of antivenom from reference hospitals to community healthcare centers in the Brazilian Amazon are more effective strategies that would to maximize access to antivenom treatment.

Providing Antivenom Treatment Access to All Brazilian Amazon Indigenous Areas: 'Every Life Has Equal Value'

Snakebites are more frequent in the Brazilian Amazon than in other parts of Brazil, representing a high cost for the health system since antivenoms are only available through medical prescription from central municipal hospitals in most cases. The need for a cold chain and physicians usually restricts access to the only effective treatment of a snakebite, the antivenom. The complex topography of the rivers contributes to delays in treatment, and consequently increases the risk of severe complications, chronic sequelae and death. Thus, decentralization of antivenom treatment to primary healthcare facilities in the interior would increase access by indigenous population groups to proper healthcare. To standardize and evaluate the decentralization to low complexity indigenous healthcare units, we suggest the (i) development and validation of standardized operational procedures, (ii) training of professionals in the validated protocol in a referral health unit, (iii) implementation of the protocol in an indigenous healthcare unit, (iv) assessment of perceptions towards and acceptability of the protocol, and (v) estimation of the impact of the protocol's implementation. We expect that antivenom decentralization would shorten the time between diagnosis and treatment and, as such, improve the prognosis of snakebites. As health cosmology among indigenous populations has an important role in maintaining their way of life, the introduction of a new therapeutic strategy to their customs must take into account the beliefs of these peoples. Thus, antivenom administration would be inserted as a crucial therapeutic tool in a world of diverse social, natural and supernatural representations. The information presented here also serves as a basis to advocate for support and promotion of health policy initiatives focused on evidence-based care in snakebite management.

Snakebites in Rio Branco and surrounding region, Acre, Western Brazilian Amazon

INTRODUCTION

Snakebites are considered a neglected tropical disease in many countries in Latin America, including Brazil. As few studies have assessed snakebites in the Amazon region and especially in the state of Acre, epidemiological studies are of great importance. The present study aimed to describe the epidemiological characteristics of snakebites in the Rio Branco region, observing their characteristics in rural and urban areas and their correlation with rainfall and river outflow.

METHODS

This retrospective, descriptive study analyzed epidemiological information obtained from snakebite notifications registered on the Information System for Notifiable Diseases that occurred from March, 2018 to February, 2019. The cases of snakebite were correlated with rainfall and flow.

RESULTS

A total of 165 cases of snakebite were registered in the period. Most cases were caused by Bothrops and affected mainly individuals of the male sex who were between 21 and 30 years old. Most of the snakebites occurred in Rio Branco (71.52%; 29 cases per 100,000 inhabitants). Of these, 60.2% occurred in the urban area and 39.8% in the rural area and the majority occurred during the rainy season.

CONCLUSIONS

Although studies have shown that a majority of cases occur in rural areas, in this study, urbanization of snakebites was observed. The Bothrops genus was responsible for the highest number of snakebites and, during the rainy season, bites occurred more frequently. Educational prevention campaigns, population advice, and first aid in case of snakebites for the population are thus suggested.

Relationship between snake size and clinical, epidemiological and laboratory aspects of Bothrops atrox snakebites in the Western Brazilian Amazon

In the Brazilian Amazon, snakebites are a significant problem, especially for populations in rural areas, particularly in forests, where victims are a considerable distance from hospital care. Several factors are associated with the severity of the accident, such as the size and age of the snake. This study aims to compare the clinical, epidemiological and laboratory aspects of envenomation to the size of Bothrops atrox snakes. Clinical, epidemiological and laboratory variables were collected from patients bitten by B. atrox and who were admitted to a hospital in the city of Cruzeiro do Sul (western Brazilian Amazon). When the two punctures of the teeth were present in the bite sign, the distance between these was measured. When taken to the hospital, the snake was measured; otherwise, its size was estimated via interviews with patients. In 92 cases, the size of the snake was estimated, and most of these were caused by small snakes. Bites of small snakes occur mainly on the feet, while larger specimens reach the legs or higher regions. Small snakes were associated primarily with mild and moderate snakebites, with more presence of hemorrhagic manifestations, while larger snakes were responsible for severe cases and characterized by local effects (necrosis, edema, flictena, compartment syndrome, and infection) and patients were treated with a higher amount of antivenom and for a longer period of hospitalization. The distance of the punctures was related to the size of the snake and the severity of the local envenomation. The observation of the distance between puncture marks when present, which is correlated with the length of the specimen, as well as the estimation of the snake size by the patient, may provide more support for the health professional on the prognosis of envenomation. The use of boots in activities in rural areas and forests could contribute to a lower rate of cases of snakebites, and health education on preventive measures and first aid for populations is fundamental.

Bothrops atrox, the most important snake involved in human envenomings in the amazon: How venomics contributes to the knowledge of snake biology and clinical toxinology

Bothrops atrox snakes are mostly endemic of the Amazon rainforest and is certainly the South American pit viper responsible for most of the snakebites in the region. The composition of B. atrox venom is significantly known and has been used to trace the relevance of the venom phenotype for snake biology and for the impacts in the clinics of human patients involved in accidents by B. atrox. However, in spite of the wide distribution and the great medical relevance of B. atrox snakes, B. atrox taxonomy is not fully resolved and the impacts of the lack of taxonomic resolution on the studies focused on venom or envenoming are currently unknown. B. atrox venom presents different degrees of compositional variability and is generally coagulotoxic, inducing systemic hematological disturbances and local tissue damage in snakebite patients. Antivenoms are the effective therapy for attenuating the clinical signs. This review brings a comprehensive discussion of the literature concerning B. atrox snakes encompassing from snake taxonomy, diet and venom composition, towards clinical aspects of snakebite patients and efficacy of the antivenoms. This discussion is highly supported by the contributions that venomics and antivenomics added for the advancement of knowledge of B. atrox snakes, their venoms and the treatment of accidents they evoke.